臺灣長期照顧實作指引(TW LTC IG)
1.0.0 - STU 1.0.0

臺灣長期照顧實作指引(TW LTC IG), published by 經濟部產業發展署. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Lorex/TWLongTermCare_IG_Build/ and changes regularly. See the Directory of published versions

: 轉介單居家服務計畫範例 - XML Representation

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="ltc-careplan-referral-home-service-example"/>
  <meta>
    <profile
             value="http://ltc-ig.fhir.tw/StructureDefinition/LTCCarePlanReferral"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CarePlan ltc-careplan-referral-home-service-example</b></p><a name="ltc-careplan-referral-home-service-example"> </a><a name="hcltc-careplan-referral-home-service-example"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px"/><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-LTCCarePlanReferral.html">轉介單－服務種類</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Proposal</p><p><b>category</b>: <span title="Codes:{https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw assess-plan}">Assessment and Plan of Treatment</span></p><p><b>subject</b>: <a href="Patient-ltc-patient-referral-chen-ming-hui-example.html">陳明慧 Female, DoB: 1945-03-15 ( National Person Identifier (TWN): A123456789 (use: official, ))</a></p><p><b>period</b>: 2024-02-01 --&gt; 2024-08-01</p><p><b>author</b>: <a href="PractitionerRole-ltc-practitioner-role-nurse-example.html">PractitionerRole Registered nurse</a></p><p><b>goal</b>: <a href="Goal-ltc-goal-mobility-improvement-example.html">Goal: lifecycleStatus = active; description = Advancing mobility; start[x] = 2024-01-15; note = 住民目前需要部分協助才能行走，期望透過復健訓練達到獨立行走的目標</a></p><blockquote><p><b>activity</b></p><h3>Details</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Status</b></td><td><b>Performer</b></td><td><b>Description</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://ltc-ig.fhir.tw/CodeSystem/ReferralCarePlanCS-TWLTC home-care}">居家護理</span></td><td>Not Started</td><td><a href="Organization-ltc-organization-example.html">Organization 新北市私立安康老人長期照顧中心（養護型）</a></td><td>提供居家護理服務，如換藥、傷口照護、健康評估等</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Status</b></td><td><b>Performer</b></td><td><b>Description</b></td></tr><tr><td style="display: none">*</td><td><span title="Codes:{http://ltc-ig.fhir.tw/CodeSystem/ReferralCarePlanCS-TWLTC home-swallowing}">居家吞嚥</span></td><td>Not Started</td><td><a href="Organization-ltc-organization-example.html">Organization 新北市私立安康老人長期照顧中心（養護型）</a></td><td>提供居家吞嚥訓練與相關照護服務</td></tr></table></blockquote><p><b>note</b>: @2024-01-20</p><blockquote><div><p>個案需要居家照顧及復健服務，由照管中心評估後安排服務提供單位</p>
</div></blockquote></div>
  </text>
  <status value="active"/>
  <intent value="proposal"/>
  <category>
    <coding>
      <system
              value="https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw"/>
      <code value="assess-plan"/>
    </coding>
  </category>
  <subject>🔗 
    <reference value="Patient/ltc-patient-referral-chen-ming-hui-example"/>
  </subject>
  <period>
    <start value="2024-02-01"/>
    <end value="2024-08-01"/>
  </period>
  <author>🔗 
    <reference value="PractitionerRole/ltc-practitioner-role-nurse-example"/>
  </author>
  <goal>🔗 
    <reference value="Goal/ltc-goal-mobility-improvement-example"/>
  </goal>
  <activity>
    <detail>
      <code>
        <coding>
          <system
                  value="http://ltc-ig.fhir.tw/CodeSystem/ReferralCarePlanCS-TWLTC"/>
          <code value="home-care"/>
          <display value="居家護理"/>
        </coding>
      </code>
      <status value="not-started"/>
      <performer>🔗 
        <reference value="Organization/ltc-organization-example"/>
      </performer>
      <description value="提供居家護理服務，如換藥、傷口照護、健康評估等"/>
    </detail>
  </activity>
  <activity>
    <detail>
      <code>
        <coding>
          <system
                  value="http://ltc-ig.fhir.tw/CodeSystem/ReferralCarePlanCS-TWLTC"/>
          <code value="home-swallowing"/>
          <display value="居家吞嚥"/>
        </coding>
      </code>
      <status value="not-started"/>
      <performer>🔗 
        <reference value="Organization/ltc-organization-example"/>
      </performer>
      <description value="提供居家吞嚥訓練與相關照護服務"/>
    </detail>
  </activity>
  <note>
    <time value="2024-01-20"/>
    <text value="個案需要居家照顧及復健服務，由照管中心評估後安排服務提供單位"/>
  </note>
</CarePlan>